Forms

Forms for New & Current Patients

New Patient Packet

• New Patient Packet (English PDF) (Rev. 10/2024)

• New Patient Packet (Spanish PDF) (Rev. 10/2024)

Consent for Treatment & Billing Practices

• Consent for Treatment and Billing Practices (English PDF) (Rev. 09/2024)

• Consent for Treatment and Billing Practices (Spanish PDF) (Rev. 09/2024)

• Consent for Treatment and Billing Practices (Tagalog PDF) (Rev. 09/2024)

• Consent for Treatment and Billing Practices (Samoan PDF) (Rev. 09/2024)

Sliding Fee Discount Application

• For an online form, text “TEXT ME” to 907-743-7200.

• Sliding Fee Discount Application (English PDF) (Rev. 12/2025)

• Sliding Fee Discount Application (Spanish PDF) (Rev. 12/2025)

• Sliding Fee Discount Application (Tagalog PDF) (Rev. 4/2025)

• Sliding Fee Discount Application (Samoan PDF) (Rev. 4/2025)

Dental Health History

• Dental Health History (English PDF) (Rev. 9/2023)

• Dental Health History (Spanish PDF) (Rev. 9/2023)

Personal Health Information Disclosure Agreement

• For an online form, text “TEXT ME” to 907-743-7200.

• PHI Disclosure Agreement (English PDF)

• PHI Disclosure Agreement (Spanish PDF)

Request a Refill of an Existing Prescription

If your prescription is at an outside pharmacy like Fred Meyer, Carrs, Walgreens, please contact that pharmacy directly.

• Existing ANHC prescriptions only: Online prescription refill request form

• You may also send an email to prescriptions@anhc.org or call our 24/7 refill line 907-743-7208.​

Request a New Prescription

• To contact your ANHC care team to request a new prescription, text “TEXT ME” to 907-743-7200.

• Online prescription refill request form

Request My Medical Records

To request that your medical records be sent to you, text “TEXT ME” to 907-743-7200.

Looking for your vaccine records? Download the Docket app for easy access.

• Apple users: Download Docket from the App Store.

• Android users: Download Docket from Google Play.

Request a Release of Information

Request that your medical records be sent to ANHC, request that ANHC send your medical records to another provider, or request a mutual exchange of information.

• For an online form, text “TEXT ME” to 907-743-7200.

• Advanced Authorization for Release of Information Request Form (English PDF) (Rev. 8/2025)

• Advanced Authorization for Release of Information Request Form (Spanish PDF) (Rev. 9/2024)

Make a Care Request

Request a different provider or make a complaint about the care you received at ANHC.

• For an online form, text “TEXT ME” to 907-743-7200.

• View other feedback options.